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APPLICATION FOR PERMIT r� u SAN JOAQUIN LOCAL HEALTH DISTRIC�% 1601 E. H LT AZE� I •N AVE., STOCICTON, CA Telephone -(209) 466-6781 t 1 PERMIT EXPIRES 1 -YEAR FROM DATE ISSUED (Complete in Triplicate) ENWOMENNTAI HEALTH rk�nMl� /SERVICES Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the erein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address / 'S 32 / 1 C1 , ' _ 1 City J440,61, 1 nt R;7p PM I nereoy cerury Mat i nave prepared tnls application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Heafth District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub -contracting signature certifies the fohowing: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant m I t call for all req ired inspections. Complete drawing on everse side. \ '�J Sig � Title; _ ' Date: FO 1 D ARTMENT USE ONLY (� L Application Accepted by - Date , ` h Area411 Pit or Grout Inspection by Date Final Inspection by,v! Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Li Manteca a23-7104 ❑ Tracy, 835-6385 Applicant - Return all copies to; Environmental Health Permit/Services 1601 E. Hazelton Ave,; P.O. Box 2009, Stk., CA 95201 r EH 13-24 MEY. /ink EH 1428 FEE INFO r - r Owner's Name t t Address �( % 7 Phone rr- Contract3�c 641- p� Address _4? — License Nodj � Phone TYPE OF WELL/PUMP: NEW WELL L _ WELL REPLACEMENT O DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES ...... __ DISPOSAL FLD. PROP. LINE j�PljE/JRMITNvO. FOUNDATION AGRICULTURE WELL OTHER WELL _ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , ❑ Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing .Domestic/Private ❑ Gravel Pack U Tracy Type of Casing . Specifications i I Public 71 Other D Delta Depth of Grout Seal Type of Grout___ i I Irrigation _..Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump_._ H. P. �._ ____ State Work Done Well Destruction O Well Diameter Sealing Material (top 501 Depth ____ Filler Material (Below 50) TYPE OF SEPI IC WORK: NEW INSTALLATION I 1 REPAIR%ADDITION I ' DESTRUCTION I ; 1No septic system permitted if public sewer is available within 200 feet.) Installation will servo: Residence — Commercial _ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ...... Water table depth SEPTIC TANK ❑ Type/Mfg - Capacity _ No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE r ❑ No. & Length of lines _ _ Total length/size--- ength/size -_FILTER FILTERBED O Distance to nearest: Well Foundation __ Property Line SEEPAGE PITS I I Depth ._Size _ _' s T ,Number _ SUMPS._--,,,.- „^ _ LJ - Distance to .nearest: -Well Foundation- Property Line DISPOSAL PONDS D I nereoy cerury Mat i nave prepared tnls application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Heafth District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub -contracting signature certifies the fohowing: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant m I t call for all req ired inspections. Complete drawing on everse side. \ '�J Sig � Title; _ ' Date: FO 1 D ARTMENT USE ONLY (� L Application Accepted by - Date , ` h Area411 Pit or Grout Inspection by Date Final Inspection by,v! Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Li Manteca a23-7104 ❑ Tracy, 835-6385 Applicant - Return all copies to; Environmental Health Permit/Services 1601 E. Hazelton Ave,; P.O. Box 2009, Stk., CA 95201 r EH 13-24 MEY. /ink EH 1428 FEE INFO AMOUNT AMOUNT REMITTED CASH CK RECEIVED BY CASH DATE �D\jUE j�PljE/JRMITNvO.